CULTURAL COMPETENCY IN ADOLESCENT MEDICINE:

DOES IT MATTER?David Breland MD MPHAssistant Professor of PediatricsDivision of Adolescent MedicineSeattle Children’s Hospital

OBJECTIVES

Historical prospective Cultural competency/effectiveness

Definitions Value Conceptual frameworks

Why important in Adolescent Medicine/Health Suggestions on how to approach cultural

effectiveness in adolescence Discussion Videos

2.11 min

HISTORICAL CONTEXT IS IMPORTANT

In the past….. Separate and unequal administration of health

care Negative acknowledgement of different races Bias of researchers and clinicians unchecked African American nurses and doctors not allowed

to join medical societies

Now…. Culture of medicine still seen as key to

transmission of stigma, racial bias and the development of health disparities across minority groups

Inequity of health care

HEALTH EQUITY

The absence of systematic disparities in health AND

in the major social determinants of health BETWEEN

social groups who have different levels of underlying social advantage/disadvantage

SEARCH FOR HEALTH EQUITY

Recognized need for health equity Medical errors not explained fully by

socioeconomics Focus on increasing diversity in workforce Need for diversity in research Cultural competence

WHAT IS CULTURE?

Anthropologist Not a single variable but comprises multiple

variables affecting all experiences Inseparable from economic, political, religious,

psychological and biological conditions Ordinary activities/conditions take on emotional

tone and moral meaning for participants Often differ within the same ethnic or social

group because of differences in age cohort, gender, political association, class, religion, ethnicity and even personality

CULTURALLY COMPETENT CARE

“Ability of health care providers and institutions to deliver effective services to racially, ethnically and culturally diverse

populations”

WHY CULTURAL COMPETENCY?

Cultural competency/effectiveness Fashionable term! No one can define the term to operationalize

Clear that it does matter in clinical settings Cultural factors crucial to

Diagnosis Treatment Ongoing care

Shapes health-related beliefs, behaviors and values

CULTURALLY EFFECTIVE CARE

AAP “the delivery of care within the context of

appropriate physician knowledge, understand, and appreciation of all cultural distinctions leading optimal health outcomes”

AMA Advises clinicians to assess ethnic identity and

acculturation of minority and immigrant youth in clinical practice

Delivering Culturally Effective Health Care to Adolescents by Fleming and Towey 2001

Key is to recognize there are differences

PROBLEMS WITH THE IDEA OF CULTURAL COMPETENCY

Suggest that culture can be reduced to a technical skill for which clinicians can be trained and develop expertise Problem stems from medical definition of culture

Often synonymous with ethnicity, nationality and language

Cultural factors not always central to a case May hinder a more practical understanding of

the case Historically

Culture in health care solely domain of patient and family

Can also talk about culture of health care

WHAT IS THE VALUE?

Large claims of value for cultural competence not supported by robust evaluation research showing improvement in clinical services

Might be a failure of outcomes research to take it seriously to evaluate its cost effectiveness Consumer Assessment of Healthcare Providers and

Systems (CAHPS) Standardized survey instruments used to collect reliable

information from patients about the care they received Assess racial/ethnic and language differences in patient

experiences with care CAHPS Cultural Competence (CC)

Weech-Maldonado et al, Medical Care, Vol 50, 9(2): 2012

REVISED CULTURAL FORMULATION (BASED FROM DSM IV)

Step 1: Ethnic/cultural Identity Ask about ethnic/cultural identity and see if matters Acknowledge and affirm a person’s experience with

illness Don’t assume knowledge

Step 2: What is at stake? What is at stake as patient and family face illness Shed light on the moral lives of patients and

families Step 3: The illness narrative

Reconstruct the patient’s illness narrative to acquire understand of the meaning of illness

Explanatory model

REVISED CULTURAL FORMULATION CONTINUED

Step 4: Psychosocial stresses Consider ongoing stresses and social support that

make up people’s lives (i.e. family tension) Step 5: Influences of culture on clinical

relationships Clinician critical self reflection Unpack the formative effects that the culture of

biomedicine and institutions has on the most routine clinical practices

Step 6: The problem of a cultural competency approach Efficacy!! Does this intervention actually work in a all cases?

GROWING DIVERSITY OF THE ADOLESCENT POPULATION

Most adolescent minority populations are growing faster than the white populations

By 2040 the projected % of non-Hispanic whites in the adolescent population will drop below 50%

Hispanics are becoming the second most populous ethnic group

Asian/Pacific Islander, though small in number, are growing at the fastest rate

The American Indian/Alaska Native population is projected to remain largely unchangedSource: National Adolescent Health Information Center. 2000

OTHER KEY FACTORS TO CONSIDER IN ADOLESCENCE

SES Educational attainment Population characteristic and access to

health care Family structure and dynamics Culture of Western medicine Culture’s influence on health care Health beliefs and practices

ASSESSING CULTURAL FACTORS WITHIN A HEALTH HISTORY

Integrating adolescent patients’ cultural backgrounds in health assessments can help facilitate communication

Asking about significance of their behavior w/in the context of their cultural background

Avoid assessment based on dominant culture norms

Critical factors SES, educational attainment, family structure

and dynamics, cultural beliefs and practices, ethnic origin/identification and language preference

UNDERSTANDING ADOLESCENTS’ PERSPECTIVES ON THEIR HEALTH

PROBLEMS

1. How would you describe the problem that brought you to me?

2. What name do you give your problem/illness?3. Why do you think this problem has happened to you?4. What do you think will help treat your health

problem?5. Are there things that make you feel better that

doctors do not know about?6. What do you fear most about your illness?7. Apart from me, who else do you think can help you

get better?8. Has anyone else helped you with this problem?9. What are the chief problems your illness has caused

you or your family?

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REFERENCES Kleinman A, Benson P, Anthropology in the Clinic:

The Problem of Cultural Competency and How to Fix it. PLoS Medicine,3(10) 2006: 1673-76.

Vo DX, Park MJ, Racial/Ethnic Disparities and Culturally Competent Health Care Among Youth and Young Men. Am Journal of Men’s Health, 2(2) 2008: 192-205.

Weech-Maldonado R, Carle A, et al, The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cultural Competence (CC) Item Set. Medical Care, 50(9) suppl 2, 2012: S22-S31

Fleming M, Towey K, Delivering Culturally Effective Health Care to Adolescents. American Medical Association, 2001.

QUESTIONS?

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